The true cost of treating children

Episódios de cuidados: um conceito em saúde pública

INTRODUÇÃO: Esse artigo apresenta uma revisão da literatura sobre a definição de episódio de cuidados. O conceito de episódio de cuidados na pesquisa em serviços de saúde emergiu nos anos 60. Os episódios têm sido descritos em três perspectivas diferentes: a do paciente (episódio de mal estar), a do prestador do serviço (episódio de doença) e do seu financiador (episódio de cuidados). OBJETIVO: O principal objetivo desse estudo é apresentar uma revisão da literatura da definição operacional de episódio de cuidados. METODOLOGIA: Uma pesquisa bibliográfica foi realizada no período de 1950 a 2007 foram identificados por meio de pesquisa computadorizada à base de dados Medline. RESULTADO: Após a seleção dos artigos cinquenta e quatro artigos foram incluídos para a revisão da definição operacional de episódio de cuidados. CONCLUSÃO: As definições de episódios de cuidados diferem grandemente na literatura. A definição operacional mais apropriada de episódios de cuidados a ser utilizada deve ser determinada pelo objetivo do estudo, bem como pelas vantagens e limitações da metolodologia utilizada.

Correlation between severity of disease and reimbursement of costs in neonatal and paediatric intensive care patients

AIM

The aim of the present study was to investigate the correlation between neonatal, paediatric and adult disease severity scores and reimbursement by health insurances.

METHODS

The setting was a university hospital's neonatal intensive care unit (NICU) and paediatric intensive care unit (PICU). We performed a prospective study of all patients admitted over the 3-month study period. Data collected included five scoring systems to predict mortality or to quantify disease severity (Paediatric Index of Mortality [PIM], Paediatric Risk of Mortality [PRISM], Simplified Acute Physiological Score [SAPS], Score for Neonatal Acute Physiology [SNAP], Therapeutic Intervention Scoring System [TISS]) on a daily basis, the total reimbursement as calculated by the grouper according to the German diagnosis-related groups (DRG) system, age of the patient, length of stay (LOS), International Classification of Diseases (ICD)-10 and DRG diagnosis. Our intention was to determine the correlation between different neonatal, paediatric and adult scores (PIM, PRISM III, SAPS-II, SNAP, Core-10-TISS), and reimbursement by the health insurance on the basis of the German DRG system in its 2005 and 2007 version.

RESULTS

No positive correlation between any score applied and reimbursement by the health insurance could be identified. Reimbursement was positively correlated to the length of hospital stay. Positive correlations could also be shown for some of the scores among each other.

CONCLUSION

We conclude that other scoring systems or measures of disease severity urgently need to be established to terminate the chronic underfunding of paediatric intensive care medicine in the developed countries.

The pediatric subspecialty workforce: public policy and forces for change

Policy has not adequately addressed the unique circumstances of pediatric subspecialties, many of which are facing workforce shortages. Pediatric subspecialties, which we define to include all medical and surgical subspecialties, are discrete disciplines that differ significantly from each other and from adult medicine subspecialties. Concerns about a current shortage of pediatric subspecialists overall are driven by indicators ranging from recruitment difficulties to long wait times for appointments. The future supply of pediatric subspecialists and patient access to pediatric subspecialty care will be affected by a number of key factors or forces for change. We discuss 5 of these factors: changing physician and patient demographics; debt load and lifestyle considerations; competition among providers of subspecialty care; equitable reimbursement for subspecialty services; and policy to regulate physician supply. We also identify issues and strategies that medical and specialty societies, pediatric subspecialists, researchers, child advocates, policy makers, and others should consider in the development of subspecialty-specific workforce-policy agendas.

Adult survivors of pediatric illness: the impact on pediatric hospitals

CONTEXT

Patients now live well into adulthood surviving diseases with pediatric onset. The size and financial impact of this growing population is unknown.

OBJECTIVE

To describe the demographics of adult inpatients in pediatric facilities and to assess the financial impact of providing care for these patients on freestanding children's hospitals.

DESIGN AND DATA SOURCES

An observational study using the Pediatric Health Information System, a proprietary database available to Child Health Corporation of America member hospitals, covering years 1994-1999. These data reflect inpatient services and exclude outpatient encounters and adult patients transitioned to adult providers. National estimates of the number of adult survivors of pediatric illness and the financial impact of care were calculated. Hospitals with >100 discharge events for patients > or =age 21 in 1999, and having both clinical and financial data in the dataset, assured an adequate sample size to discern resource utilization. Both 18 and 21 were used as lower limits of adult age to reflect common definitions of legal majority (age 18) and common pediatric practice (age 21). We truncated the data at age 64 to exclude patients eligible for Medicare.

RESULTS

Ten hospitals representing all geographic regions of the United States were used for an in-depth analysis of financial impact during 1999. Six of 10 had data for 1994-1999 to describe trends over time. The number of patients admitted over the 6-year period increased, as did average and total adjusted charges. In 1999, 3863 patients 18 to 64 years old incurred 5051 discharge episodes and total charges of $134.5 million. Of these, about half (1785) were > or =21 with charges of $66 million. Of the hospitals' total discharges and financial charges, on average 2.1% and 3.1%, respectively, were from the inpatient care of patients 21 to 64 years old. Forty percent of patients receive public aid. Extrapolating from census data, up to 15 000 patients > or =21 years annually may seek inpatient care in part at children's hospitals, with charges exceeding $500 million. The 3 most common diagnostic groups to be admitted were those with cystic fibrosis, mental retardation or cerebral palsy, and congenital heart disease.

CONCLUSIONS

We describe a subset of adults who have survived diseases of pediatric onset. We focused on the portion of that population that obtains at least some inpatient care at a children's hospital. The data reported here can be used to set a lower boundary for the size of this population, and thereby provide valuable data for health planners as well as clinicians. If one includes estimates of expenses across the continuum of care, the financial impact of this growing population is substantial. Public policy discussions should include the medical, psychological, social, and financial needs of this population.